Critical analysis of the scientific production on Jean Watson’s Theory of Human Care

ABSTRACT Objectives: to analyze current scientific production on the use of the theoretical-methodological precepts of Jean Watson’s Theory of Human Care/Clinical Caritas Process. Methods: quantitative, exploratory, descriptive study using data from 1979 to 2023 in the Scopus database. Analysis was carried out using VOSviewer software. Results: the 73 studies included establish a network of collaboration among 221 authors from 155 institutions in 18 countries, who discuss the development of ethical behavior in nursing staff, through technical improvement, implementation, and validation of instrumental strategies capable of measuring and evaluating the quality of holistic and empathetic care. The Theory of Human Caring contributes to nursing training and care, and Process Clinical Caritas-Veritas is useful for the different possibilities of practice and education. Conclusions: it is important to strengthen with more empirical data a nursing work model centered on individual human care, supporting the evolution of scientific nursing knowledge.


INTRODUCTION
Knowledge production is linked to the need to develop references capable of guiding the path of thought.This contemplates a distinct action capable of consolidating relationships between those who produce knowledge and those who will benefit through care actions.Nursing is the profession of care, and this is the basis of action developed in all healthcare environments around the world (1) .
The theoretical-philosophical bases, values and worldviews transcend specific issues and seek to provide universal understanding of reality, in addition to ethical-philosophical reflection for all fields of study (2) .Thus, it is understood that nursing configures its knowledge with the multiplicity of knowledge production.
Nursing theories point to the construction of this multiple knowledge, providing theoretical and practical material for carrying out daily care actions.Validated knowledge contributes to the advancement of the profession, as it fills the gap in debates and reflections on nursing practice.Theories and concepts consolidate the conceptual interrelations of knowledge itself, establishing and determining a logical relationship of critical thinking (3)(4) .
Among these, the focus of this study is the thought and assumptions defended by Jean Watson.Recognizing the actions disciplined by theories as an intrinsic activity of the nursing profession is admitting the establishment of interpersonal relationships in work routine and, with this, building social, emotional and spiritual experiences between nurses and patients.
Watson's philosophy is based on a belief that caring is a moral ideal rather than a task-oriented one and that people take care of themselves to care for others.Watson sees nursing as a profession and caring as a vocation based on an ethical agreement linked to humanity (12) .She also considers care as something innovative, capable of strengthening nurses' practice and leadership in the health field.Furthermore, her care proposal based on body-mindsoul integration is necessary as a tool to support patients' and families' experience and understanding about the disease and healing process (13) .Care advocated by Watson requires a deep connection between nurses and patients throughout every moment of care.
Care is transpersonal and provides the opportunity to explore feelings and emotions beyond technical-procedural nursing actions.
Relationships are interpersonal and promote the bond between body and mind based on "caring-healing" perception (14) .In other words, experiences acquired through interpersonal relationships between nurses and patients transcend the perception of being, and acquire consciousness connected with persons cared for and persons who care.It is an intersubjective idea that shares the both participants' life story in the moment of care (13)(14)(15)(16) .The Theory of Human Caring is based on a system of values built on a holistic perspective and a unitary worldview that refers to a transpersonal experience of the body, spirit and soul, created at the moment of care, and interpersonal relationships between nurses and patients.From this perspective, Jean Watson guides transpersonal care through the recognition of the "healing" awareness.This awareness, called Caritas, is a unity that means "being present in the moment of care" (13)(14)(15)(16) .
This understanding of genuine care in a true moment becomes evident in the evolution of the theory from 1980 onwards.In 1985, the first paradigm consisted of care based on factors formed by a humanistic-altruistic value system (16) .The second paradigm, in 2008, shows an even greater approach to care when it begins to assume authentic awareness through elements that support the transpersonal relationship and, then, expands to Clinical Caritas Process (12) .After ten years, Jean Watson presents her third paradigm, which involves nurses' transcendence to an evolved awareness, open to the cosmic-divine and to love, adding key elements in more authentic care and expanding to Caritas-Veritas Clinical Process.In this third paradigm, Jean Watson states that care is a unique phenomenon and recognizes that it must occur in a unitary manner and, thus, proposes an expansion of understanding about the evolution of the Theory of Human Caring to Science of Unitary Care.In this regard, the perspective of care establishes a way of perceiving the world and relating in a way that emphasizes the transformative meaning of caring and being cared for, i.e., recognizing the interaction of the relationship as a unitary experience of thought, body, soul and spirit during the moment of care (17) .
Bearing this in mind, the guiding question arose: what is the overview of international scientific production regarding Jean Watson's Theory of Human Caring?It is important to highlight that, by understanding this overview, it will be possible to preserve and convey technical-scientific knowledge about holistic and empathetic care.
The justification for this study is the understanding that the purpose of gathering experiences about research on human care will help in proposing new perspectives, given the evolution of the worldview and relationships between people that the theory presents.Furthermore, it will guide new research through the production of important scientific knowledge for the evolution of nursing practice based on unitary and intentional theory, emphasizing the connection of care experiences between nurses and patients.

OBJECTIVES
To analyze current scientific production regarding the use of the theoretical-methodological precepts of the Theory of Human Caring/Clinical Caritas Process created by Jean Watson.  of Critical analysis of the scientific production on Jean Watson's Theory of Human Care Afonso SR, Padilha MI, Neves VR, Elizondo NR, Vieira RQ.

METHOD Ethical aspects
The study used secondary documentary sources indexed in a database and, therefore, did not require approval from the Research Ethics Committee.

Study design
This is a study with quantitative, exploratory and descriptive characteristics, with a bibliometric analysis design (18) .In this study, a hybrid model was applied through the systematization of a set of phases and stages, seeking to investigate the overview, applications and results obtained.Thus, the study was divided into two phases: 1. Search in the database; and 2. Bibliometric analysis.

Data collection and organization
Data collection was carried out in the Scopus database, using the PRISMA 2020 Statement to present the definition of selected scientific articles systematically (19) .The search was carried out in March 2023.The intention to search in a single database was because Scopus can be considered a broader, more democratic database, containing a greater number of qualified journals than in other databases.
Although it follows the guidance of a bibliometric study, it was decided to search for systematic review based on a research question.The PCC strategy was adopted using the acronym for Population (Nursing), Concept (Theoretical-methodological precepts) and Context (Jean Watson's Theory of Human Caring), with the concepts and contexts of the following terms being identified in the abstracts of the studies to be selected: Carative Factors, Watson  Watson).When considering the historical context, we chose to search for terms that expressed the implementation of the theory from 1979 to 2023, taking into account the various conceptions adopted over time.Inclusion criteria included original scientific articles with an approach to patient care based on the Theory of Human Caring, the relationships between the theory and nursing training, and the processes of implementing the theory in nursing work.
Exclusion criteria included conditions in which the theory was used only to compare with another nursing theory, conceptual approach to the theory of care, but without a link to the theory defended by Jean Watson, repeated work, review research (secondary research) and work without presenting abstracts.
The first stage of identification consisted of using the search strategy TITLE-ABS-KEY (Watson's AND theory AND of AND caring) AND (LIMIT-TO (DOCTYPE, "ar")).The term "Watson's Theory of Caring" was restricted to the title, abstract or keywords fields to find 279 indexed documents in the Elsevier report indexed in Scopus until the date of information extraction, on March 25, 2023.After implementing the inclusion and exclusion criteria, 73 articles remained for the analysis of scientific production presented in Figure 1.

Data analysis
The difference between the number of documents located and articles included in the analysis highlights PRISMA methodology's relevance to produce a systematic review and analyzes using bibliometric indicators, as it allows minimizing the emergence of biases.Data analysis was initially carried out using the bibliometric method, which identified the most comprehensive setting in the literature, outlining the evolution and development of the topic studied.In this case, it was carried out using quantitative indicators from descriptive statistical sample to create graphic elements.Data were exported in "*.csv" format for bibliometric analysis in software, in order to treat them statistically by bibliometric networks in VOSviewer version 1.6.9 (18,20).To organize qualitative information, data were tabulated in a Microsoft Excel 365 file, identifying abstracts, authorship, year of publication, institutional affiliation, journalo, method used and theoretical approach.This organization constituted an overview of systematic analysis, allowing the identification of gaps and trends in scientific production.

RESULTS
Initially, works published from 1979 to 2023 were identified, however, after reading the abstracts, those that addressed the Theory of Human Caring/Clinical Caritas Process as the scope of the investigation were selected, which restricted selection to 2000 to 2022.There was no indexing of works in Scopus in 2005 and 2007; however, it is not possible to state the reason for the lack of research on the topic in journals during this period.An increase in the number of studies in indexed journals was identified in 2020 and 2021, highlighting a trend in the discussion about the theory.The year 2020 concentrated 11 studies  in different journals (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31) .And 2021 recorded one study in each journal, with Revista Brasileira de Enfermagem standing out with three articles (32)(33)(34)(35)(36)(37)(38) .
The 73 articles that made up the sample are distributed across 47 journals.When observing dispersion of scientific production on Watson's Theory of Human Caring, it was decided to arrange the journals into three groups, considering the total number of studies in each.The first group is made up of journals with a range of three and eight studies, and the second group has two studies each.The third group is made up of journals that include one study each.Chart 1 highlights the publication sources with the highest volume of articles in the investigated sample.
In relation to the journals with the highest publication volume, Nursing Science Quarterly stands out, which accounts for 33.3% of group 1 of studies in the study sample, followed by Journal of Advanced Nursing and Journal of Holistic Nursing, with 20.83% each, and Ciencia y Enfermería and Revista Brasileira de Enfermagem, which account for 12.5% each of the journals with the largest volume of published works.The other journals in group Chart 2 lists the most influential publications on the topic, considering the volume of citations received by other articles published in journals indexed in Scopus.The minimum number of 35 citations made among articles' internal citation network was used as a cut-off criterion, resulting in eight articles that met this criterion, such as: It is worth highlighting that the most influential journal, in relation to publications about Watson's Theory of Human Caring, is the Journal of Advanced Nursing, which presents two of the eight most cited articles.Despite identifying Nursing Science Quarterly with the highest publication volume, presenting eight articles in its editions, the most cited journal was Dimensions of Critical Care Nursing, followed by the Journal of Advanced Nursing, with a volume of five publications in its editions, when compared to results in Charts 1 and 2. The references with the greatest impact were "Caring Science as Sacred Science", with nine citations, "Postmodern Nursing and Beyond", with 11 citations, and "Nursing: The Philosophy in the Science of Caring", with citations, all publications by Jean Watson.The countries with the greatest impact on publications were the United States, with citations in 23 documents, followed by Canada, with 135 citations in six documents, Turkey, with 59 citations in ten documents, and Brazil, with 32 citations in 12 documents.
Authors with at least three articles indexed in the database and ten citations participated in the bibliographic coupling of

Critical analysis of the scientific production on Jean Watson's Theory of Human Care
Afonso SR, Padilha MI, Neves VR, Elizondo NR, Vieira RQ.
network, or scientific knowledge network, generating a network of ten authors, grouped into three clusters.Each researcher in a cluster tends to cite the same authors as the other participants in the same cluster.The first cluster brought together four most productive researchers, Jean Watson and Marlaine Smith, from the University of Colorado Health Sciences Center, Denver, Colorado, with 112 citations, representing a strong connection to the other researchers in this network (40) .In the second cluster, consisting of three authors, Sylvie Cossete, Jose Cote, Jacinthe Pepin, Nicole Ricard and Louis-Xavier D'Aoust, Faculty of Nursing, University of Montreal, Quebec, Canada, in 2006 stand out, with 35 citations and eight sources of links with other researchers (51) .In the third cluster, formed by three authors, Anne Vitale had 21 citations and six connections in the network with the other researchers (86) .The studies discuss the implementation of systematized techniques for human care, highlighting the significant reduction in patients' emotions and bad feelings integrated with technological care supports based on the Theory of Human Caring/Clinical Caritas Process.The authors highlight the Caritas Process as a nursing work model to strengthen the idea of holistic health care that is attentive to patients' well-being as a whole.Therefore, they address implementation strategies to guarantee the quality of individual care and patient safety.It is possible to observe this reflection in the study entitled "Transformation of Clinical Nursing Practice Following a Caring-based Educational Intervention: A Qualitative Perspective", by Bellier-Teichmann, Tanja et al. (87) .
It was possible to identify studies aimed at validating care instruments assessed by Watson's theory of care.They also addressed the implementation of standardized systems in nursing services.These works discussed the importance of establishing an individual care relationship and developing clinical skills, using interaction scales and appropriate models for care.They emphasized that work engagement increases and stressors reduce individual satisfaction, resulting in environments supported by empathy, compassion and holism, as presented in the work entitled "Compassion fatigue, moral distress, and work engagement in surgical intensive care unit trauma nurses: A pilot study", by Mason, Virginia M. et al. (82) .
Nursing care assessment based on Caritas-Veritas Clinical Process was another most debated topic among studies (24,31,35,37,(41)(42)(43)55,74,77,(87)(88)(89) . In the findings the importance of developing processes for nursing education and training centered on the process of human care was identified, involving strategies for the advancement of nursing with the reintegration of essential activities that meet patients' needs and guarantee quality of life.
When discussing nursing staff's ethical behavior during patient care, the authors draw attention to the types of interpersonal relationships established with patients.They consider that clinical competence is important to emphasize the notion of human care, integrating environments and moments of care with patients and other nursing professionals (68,71) .

DISCUSSION
The main topics discussed were: nursing staff's ethical behavior during patient care; theoretical-philosophical reflections on the theory of care and its advantages for nursing training; strategies to systematize nursing care through the implementation of standardized care techniques/protocols based on Caritas-Veritas Clinical Process; and validity of care instruments to record and measure Watson's moment of nursing care.(2014) (82) Compassion fatigue, moral distress, and work engagement in surgical intensive care unit trauma nurses: A pilot study  (71) The butterfly effect of caring -clinical nursing teachers' understanding of self-compassion as a source to compassionate care
This reflection is seen in consolidated studies carried out by the Observatory on Science, Technology and Innovation (OSTI), which verified a growth in scientific production of 32.2% in 2020.In the report issued, scientific productions between 2015 and 2020 were measured and compared.It was found that, in the face of the pandemic, the work presented by researchers contributed to the development of social references, diagnoses and treatments, expanding relevant knowledge for implementing strategies to combat the coronavirus (94) .
The high participation of publications carried out in the United States, Canada and Turkey corresponds to the percentage noted in this report regarding international collaboration (94)(95)(96)(97)(98)(99) .There is an interest in consolidating the concept of internationalization of science and establishing rapprochement between research centers and, with this, one can see the establishment of cooperation networks of references and study trend groups centered on terms such as "Caring", "Nursing" and "Nursing Theory".
The performance of the networks established in this analysis points to the tendency of knowledge production between countries regarding the Theory of Human Caring according to Watson and, therefore, they claim its importance as an approach in journal submissions.This statement is corroborated in the reflections made by Guerrero-Castañeda and Chávez-Urías (22) , who claim to be a theory used constantly in nursing processes, as its holistic perspective is centered on the construction of the values of interpersonal relationships, awakening a fundamental awareness for the professional practice of the area, which is care centered on patients and their needs.
The quality of nursing care can enhance the involvement of empathetic and holistic care, transcending technical and mechanized procedures.This is because the evolution of care recognizes the phenomenon of transpersonality between nurses and patients, and is understood as a manifestation of nursing professionalization maturation (22) .There is a tendency for nursing work to advance, and it is clear that the team's ethical behavior during patient care is one of the topics most discussed by nursing professionals (56,(90)(91)(92)(93) .It is understood that care relationships during the nursing process must find a meaning capable of helping patients during their suffering.Therefore, it is important that nursing establishes relationships of patient acceptance in this moment of care (98) .
Ethical behavior during care awakens an intersubjective relationship between nurses and patients, since both are influenced by the stories, environment and phenomenon of care.By sharing the technical relationship of care, the moment of care transcends the environment and the physical moment to the spiritual state.
This type of behavior is exemplary and focused on care, being a reference for other nurses, as there is an effort to provide care to patients holistically and empathetically.Patients perceive nurses' general care as something significant, based on changes in individual behaviors.In this sense, it is important to implement nurse education programs to provide patient care with quality nursing services (55) .
It is understood the importance of nursing professionals developing the ability to meet the needs related to the body-mindspirit of patients, considering their particularities and, therefore, the importance of establishing ethical behavior in interpersonal relationships so that care is carried out intentionally and aligned with patients' trust and beliefs (81,99) .
The moment of care must be one in which nurses dedicate themselves to action and relationships with their patients and, therefore, constitute a moment with a structure of respect for those involved.Regarding theoretical-philosophical reflections on the theory of care and its advantages for nursing training, it is possible to observe the importance given to improving nursing knowledge and its development of care, in addition to the recurring suggestions to include theoretical assumptions in the curricula of undergraduate nursing courses.This approach is also seen in other literature, highlighting the tendency towards effective and interpersonal care (81,(98)(99) .This debate consists of facilitating, integrating and contributing to nursing work evolution and to patients' healing and humanity.Effective care promotes the health and growth of patients and, therefore, the improvement of scientific nursing knowledge improves action at the time of care.
It is possible to find similar reflections in the literature that reinforce the need to rethink nursing education, highlighting the advantages of using educational technologies capable of stimulating professional identity empowerment by enhancing the apprehension of pertinent information and knowledge to develop specific skills (99) .This benefit can be used to strengthen the curriculum based on the Theory of Human Caring/Clinical Caritas Process as it allows sharing of instructions that improve the quality of the interpersonal relationship in nursing and the moment of care.
The International Council of Nurses (ICN) points out, in the description of nurses' competencies, that they must have scientific knowledge and know the basic concepts of nursing science in their training.However, the meaning of the term care and its meaning for the profession is not unanimous in nursing education programs (100) .
The Theory of Human Caring/Clinical Caritas Process educational contributions highlight the realization of the nursing process through recovery and definition of concepts of involvement.It is a statement identified in the studies analyzed, and which corroborates other authors, since the theoretical basis values human aspects and contributes to better quality nursing care, considering the complexity of care and relationships with patients (101) .Reflections on patient-centered nursing training based on the Theory of Human Caring/Clinical Caritas Process support the evolution of scientific nursing knowledge, since knowledge production improves care practice (98)(99) .
There is a tendency to develop strategies to systematize nursing care through the implementation of standardized techniques or protocols for patient care centered on Caritas-Veritas Clinical Process without losing the importance of an individualized look at patients.The most recent debates about nursing staff's behavior during individual patient care are focused on establishing spaces for human connection with patients, providing a moment of of Critical analysis of the scientific production on Jean Watson's Theory of Human Care Afonso SR, Padilha MI, Neves VR, Elizondo NR, Vieira RQ.
transpersonal care and incorporating Caritas-Veritas Clinical Process, such as intentional awareness, mindfulness, gratitude, purpose and spirituality during the nursing care process.As observed in the study "COVID-19: An Organizational-theoryguided Holistic Self-caring and Resilience Project" (45) , by investing in infrastructure for nursing professionals' holistic training, the ability to satisfy patient needs will improve care outcomes and establish better health quality indicators.
This reinforces the statements found in the literature that point to the importance of using instruments that involve the theory of care as a reference to disseminate efforts on the professional advancement of nursing (99) .
Finally, it is highlighted that Watson's Theory of Human Caring contributes to nursing training and care, and Caritas-Veritas Clinical Process can be useful for the different possibilities of practice and teaching.Nursing must integrate a simple and transformative language during nursing practice, and transpersonal care can be a positive indicator for realizing empathetic and holistic care.

Study limitations
The use of only one database for research is considered a parameter for the limits of results in this study.Furthermore, the term used is not linked in the DeCS and MeSH thesaurus database, highlighting the restriction of access to other publications on the topic studied.

Contributions to nursing
The main contributions of this study aim to analyze the Theory of Human Caring/Clinical Caritas Process theoretical direction, given its evolution.The studies pointed to the use of theory in nursing care and teaching, providing more sensitive care.Although it is a theory created in 1979, it is still alive, in force and contributing to nursing care.
The methodological path adopted allowed us to map in depth the records and elements in which relationships of scientific knowledge are produced in the individual care field.Analysis helped identify trends and growth in production volume regarding knowledge of Watson's Theory of Human Caring/Clinical Caritas Process, warning about the importance of advancing in the construction of science where knowledge gaps still exist.Furthermore, it provided records that link international reference networks and their relationships on the topic developed, meeting the most productive researchers on this topic.

CONCLUSIONS
The study made it possible to identify a trend towards the production of works focused on the topic Theory of Human Caring/Clinical Caritas Process between 2020 and 2021, and clarified the collaboration network for research between institutions in different countries.These allowed us to trace the similarity between researchers, since scientific production is significant in the use of Jean Watson's ideas to explain the evolution of her Care Theory.However, considering that only one database was used, there is little scientific production produced by the group of researchers from Latin America, requiring other studies in other databases, aiming at greater generation of empirical data about the implementation of the theory and consequently contributing to health care improvement for the population.
Hence, it was noticed that studies are focused on developing nursing staff's ethical behavior through technical improvement, implementation and validity of instrument strategies capable of measuring and assessing the quality of holistic and empathetic care.Studies identified outlined a significant time frame and with an exponential increase during the COVID-19 pandemic, highlighting the importance of care theory when providing individual patient care and contributing to expansion of knowledge in the academic community.

Figure 1 -
Figure 1 -PRISMA 2020 flowchart for new systematic reviews that included searches only in databases and records

Chart 1 -
Distribution of the main journals that published works on Watson's Theory of Human Caring, São Paulo, São Paulo, Brazil, 2023

Figure 2 -
Figure 2 -Geographic distribution of authors who developed studies related to Watson's Theory of Human CaringFigure2shows the countries of origin of the authors who published on the topic, such as the United States, with 56 authors, highlighting the University of Colorado, with eight authors; Brazil, with 51 authors, with emphasis on the Universidade Federal da Bahia, with nine authors; Turkey, with 25 authors; Canada, with 17 authors; China, with 15 authors; Chile and Switzerland, with 12 authors each country; South Africa, with six authors; Mexico, with five authors; Saudi Arabia, with four authors; Slovenia, Iran and Taiwan, with three authors each country; Iceland, Thailand and Finland, with two authors in each country; and New Zealand, with one author.It was possible to identify the temporal evolution of studies on the researched term, highlighting the number of occurrences recorded in each year from 2000 onwards, the first being published by Caroline L. Norred(38) .Of the 221 authors, around 88% (195 authors) published only one article, while 11% (25 authors) published two to three articles.The United States of America is a country with the largest volume of authors with studies on the subject of study, totaling 26 articles indexed in Scopus, with emphasis on Jean Watson (eight articles)(21,(39)(40)(41)(42)(43)(44)(45)(46) .The 73 articles that made up the sample are distributed across 47 journals.When observing dispersion of scientific production on Watson's Theory of Human Caring, it was decided to arrange the journals into three groups, considering the total number of studies in each.The first group is made up of journals with a range of three and eight studies, and the second group has two studies each.The third group is made up of journals that include one study each.Chart 1 highlights the publication sources with the highest volume of articles in the investigated sample.In relation to the journals with the highest publication volume, Nursing Science Quarterly stands out, which accounts for 33.3% of group 1 of studies in the study sample, followed by Journal of Advanced Nursing and Journal of Holistic Nursing, with 20.83% each, and Ciencia y Enfermería and Revista Brasileira de Enfermagem, which account for 12.5% each of the journals with the largest volume of published works.The other journals in group

Chart 2 -Author
Volume of citations in articles with the greatest impact, São Paulo, São Paulo, Brazil, 2023 M. et al.
Sylvie et al.(2006)(51)A dimensional structure of nurse-patient interactions from a caring perspective: Refinement of the Caring Nurse-Patient Interaction Scale (CNPI-Short Scale) Journal of Advanced Nursing 35 Canada of Critical analysis of the scientific production on Jean Watson's Theory of Human Care Afonso SR, Padilha MI, Neves VR, Elizondo NR, Vieira RQ.